Your guide to prescription drug coverage for your patients
Get a current list of pharmacies in the Community Health Plan of Washington (CHPW) network and find out which drugs are on the formulary:
COVID-19 Vaccines: The Pfizer BioNTech, Moderna, and Johnson & Johnson COVID-19 vaccines are covered as part of CHPW’s medication benefit at any location they are offered.
As of 1/1/2023 Kroger Pharmacies will no longer be in the CHPW network. For a list of all pharmacies in our network, please click the Search Pharmacies button above.
Important: The formulary and search do not apply to Medicare Advantage Plan members. Please refer to the CHPW Medicare Advantage website for information on Medicare Plan coverage.
Preferred Drug List (PDL)
On January 1, 2020, all managed care plans and Apple Health fee-for-service programs will continue to phase in a Single Preferred Drug List (PDL).
This change is mandated by the Washington State Legislature.
The Health Care Authority is working with managed care plans that serve Apple Health clients to create the Apple Health PDL. Managed-care plans will continue to use their own preferred drug lists for drugs not included in the Apple Health PDL.
Please contact [email protected] with any questions.
Carved out drugs: Covered by Fee-for-Service
The Washington State Health Care Authority (HCA) will be responsible for ALL pre-authorizations and approvals of the products found here based on HCA clinical guidelines. To request coverage please call the HCA at 800-562-3022.
➜ Carved Out Drug List Status (Last updated as of 12/22/2023)
To request a prior authorization, step therapy, nonformulary, or quantity limit override, please call ESI at 1-844-605-8168, 24 hours a day, 7 days a week, and speak to a prior authorization service specialist. This specialist will review medical information and criteria with the provider or designee regarding the need for the requested drug.
Any pharmaceutical not listed on our formulary requires prior authorization. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use https://www.CoverMyMeds.com to start the prior authorization process.
Pharmacy Reimbursement Issues
Pharmacy Emergency Fills
Emergency fills may be covered to prevent interruptions in therapy during an emergency. View our policy on emergency fills.
Medications available for 90-day fills
CHPW covers 90-day supplies for most chronic medications. Ask your physician or pharmacist for a 90-day supply of your medications at your next visit.
OTC contraceptive billing
Apple Health (Medicaid) and CHPW cover over the counter (OTC) contraception, including most emergency contraception, with or without a prescription for clients. An adjudicated pharmacy claim is required for reimbursement.
To bill OTC contraceptives, pharmacies must follow the National Council for Prescription Drug Programs (NCPDP) standard and use the national drug code (NDC) or universal product code (UPC) found on the package.
A prescription for OTC contraceptives is not required. A pharmacy may use its NPI to process a claim when a prescription is not available.
Only products that are included in the CHPW’s pharmacy system database are covered. For a list of covered OTC birth control products, see the Apple Health covered OTC contraceptive list.
Emergency contraceptives are covered. There are no limits on age, quantity, or frequency.
For more information to help patients find the birth control that’s right for them, visit the Department of Health birth control and emergency contraception page.
Personal Medication Coach Program
The Personal Medication Coach Program works with doctors and patients to ensure that medications are effective and being used correctly.
The Personal Medication Coach Program is a service for members with multiple health conditions and who take multiple medications. This program is offered through a partnership between CHPW and MedWiseRx.
- MTM Provider Credentialing Checklist
- MTM Provider and Member Requirements
- Sample MTM form (for assistance in guiding medication therapy review)
If you are looking for Medication Therapy Management for a Medicare Advantage member, visit the CHPW Medicare Advantage website for information on Medicare Medication Therapy Management information.
Patient Review and Coordination Program
Our Patient Review and Coordination (PRC) Program helps members use their medical services safely and appropriately.
Members who are selected for PRC must choose one primary care provider, pharmacy, and hospital. One primary care provider makes sure medical care and prescriptions are coordinated for the health and safety of the member.
To refer a patient to the PRC program or learn more, call us at 1-866-907-1902.
Second Opinion Program
As mandated by the legislator in RCW 74.09.490, HCA has developed the second opinion program to improve prescribing practices in children.
In collaboration with The Pediatric Mental Health Advisory Group and the Drug Utilization Review Board, HCA has established pediatric mental health guidelines to identify children who may be at high risk due to off-label use of prescription medication, use of multiple medications, high medication dosage, or lack of coordination among multiple prescribing providers.
- Apple Health Second Opinion Program Frequently Asked Questions
- Second Opinion Review Process (SON) Flowchart
Partnership Access Line (PAL)
To assist prescribers in meeting the needs of children with a mental health diagnosis, and to minimize the need for required SON review, providers can contact the Partnership Access Line (PAL). PAL is a telephone based child mental health consultation system funded by the state legislature, being implemented in Washington State. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver consultation services. The PAL team is available to any primary care provider throughout Washington State.
PCPs may call 1‐866‐599‐7257 between 8am and 5pm for any type of mental health issue that arises with any child, not just CHPW members. For additional information on the PAL visit Seattle Children’s website.
Pharmacy and Therapeutics (P&T) Committee
Our P&T Committee meets to evaluate our formulary, prior authorization requirements, and safety measures to ensure quality. Read the most recent decisions:
- November 15, 2019: No Clinical Decisions
- June 20, 2019: No Clinical Decisions
- March 25, 2019: No Clinical Decisions
- November 14, 2018: No Clinical Decisions
- July 13, 2018: No Clinical Decisions
- March 2, 2018: No Clinical Decisions
Be sure to read the latest Drug Recall Report for updates on medications that are recalled due to safety issues.